Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. INTEGUMENTARY SYSTEM Lesson # 4

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. BURNS Are painful Are often disfiguring Often require long hospitalization Often fatal May result from radiation, thermal energy, electricity, chemicals

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Major Causes Major source for all ages is sunburn Major associations in adults: Cigarette smoking Cooking Elderly Hot liquid spills Catching cloths on fire while cooking and smoking Young children Spills Playing with matches or cigarette lighter

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Classifications Based on depth and percentage estimate 1st Degree (Superficial) Epidermis only Skin hot, red and painful Involves epidermis Dry, no vesicles, blanches and refills, erythema, painful Flash flame or sunburn

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Classifications 2nd Degree (Partial thickness) Damage to dermis + epidermis Skin hot, red and painful, blisters form, tissue around the burn is edematous Usually heal in 2 weeks without scarring Large, moist vesicles, mottled pink or red, blanches and refills, very painful Scalds, flash flame

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Second Degree Burn

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. 3rd Degree (Full Thickness) All dermal structures destroyed and cannot be regenerated. Subcutaneous is also damaged. Can be white, tan, brown, black, charred or bright red in color. Destruction of nerve endings – often patients will not think burned so bad because of nerve endings not relaying correct messages, no blanching with pressure, hair pulls out easy

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Full thickness Burn 3 rd Degree

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. 4th Degree Extend to underlying muscles and bones Appear white to black or charred with dark networks of thrombosed capillaries. Results from fires, explosions and nuclear radiation Destruction of nerve endings Very painful Scarring inevitable Skin grafts necessary

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Fourth Degree Burn

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Figure 3-19 Classification of burn depth.

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Burns Medical management/nursing interventions Emergent phase (first 48 hours) Maintain respiratory integrity Prevent hypovolemic shock Stop burning process Establish airway Fluid therapy Two large venous catheters to be inserted Foley catheter Nasogastric tube

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Burns Medical management/nursing interventions Emergent phase (first 48 hours) Analgesics to control pain Monitor vital Maintain adequate oxygen level Monitor kidney function Protect burns to decrease risk of infection and help maintain body temp Tetanus

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Medical management/nursing interventions (continued) Acute phase (48 to 72 hours after burn) Treat burn Prevention and management of problems Infection, heart failure, contractures Most common cause of death after 72 hours is infection Assess for erythema, odor, and green or yellow exudate Diet: high protein, calories, and vitamins Pain control Wound care: strict surgical aseptic technique

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Medical management/nursing interventions (continued) Acute phase (continued) Range of motion Prevent linens from touching burned areas CircOlectric bed Clinitron bed Topical medication: Sulfamylon; Silvadene Skin grafts Autograft Homograft (allograft) Heterograft

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Burns Medical management/nursing interventions (continued) Rehabilitation phase Goal is to return the patient to a productive life Mobility limitations: positioning, skin care, exercise, ambulation, ADLs Patient teaching Wound care and dressings Signs and symptoms of complications Exercises Clothing and ADLs Social skills

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Life Cycle Considerations Burn Injuries in the Elderly Normal physiological changes delay recovery & increase risk for complications Physiological reserves of organ systems decrease Increased need for oxygen and cardiac output Higher risk for kidney failure Skin normally more fragile Compromised circulation Skin grafting may not be successful due to impaired circulation and impaired tissue nutrition

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Complications Amount of complications is related to pre burn heath status Loss of fluids Altered ability to maintain body temperature Susceptible to infection Initially respiratory failure and loss of body fluids are most life threatening

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Smoke Inhalation and Carbon Monoxide Poisoning Facial burns, singed nasal hair and carbon- tinged sputum are signs that client may have respiratory tract damage Inhalation of heat and smoke causes airway inflammation and edema of respiratory mucosa Inhaled carbon monoxide attaches hemoglobin, keeping oxygen from being delivered to the body. Maintaining on open airway and delivery of 100% humidified oxygen is essential.

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Shock May suffer from hypovolemic and/or neurogenic shock Neurogenic shock Occurs when peripheral vascular dilation causes hypotension. Fluids must be replaced as fast as they are lost. Fluid loss can lead to circulatory collapse and renal shutdown.

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Infection High risk of infection All persons coming into contact must wear gown, gloves, mask and caps Sterile technique is used for wound care and dressing changes

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Stabilized Care (Recovery Phase) Promote healing Prevent complications Control pain Restore function Infection control Daily cleaning and dressing changes Antibiotic and strict aseptic technique is essential

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Surgical Four types of skin grafts Autograft—clients own skin Homograft—skin obtained from a cadaver 6-24 hours after death Heterograft—skin obtained from an animal, such as a pig Synthetic skin substitute—man-made product Application of pressure dressings helps reduce scarring. Pressure dressings may be elastic wraps, stockinettes or custom-made garments

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Pharmacological Anti-infective – silver sulfadiazine ( Silvadene) (Thermazene)- second and third degree burns, burns, skin necrosis, pain – It burns, can causes skin necrosis, leukopenia or discoloration of skin and itching Antiseptics- Hibiclens, iodine A drug that stops, slows or prevents the growth of microorganisms. Germicides- benza, mycocide, acu-dyne, betadine, A drug that kills bacteria Narcotics- lanacane, lidocaine, Pain control—IV narcotics Psychotropics—decrease anxiety

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Diet Twice the normal calorie intake may be needed to meet the body’s energy needs Increased need for fluids Daily protein needs may increase 2-4 times the normal requirements High vitamin and mineral Enteral Feedings Parenteral Feedings Total Parenteral Nutrition (TPN) may be used due to decreased or stopped peristalsis.

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Activity Contractures are serious complications of burn victims Prevention Positioning Splinting Exercising Ambulation Active range of motion should be encouraged. Active exercise increases circulation, maintains joint flexibility and improves muscle tone.

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Nursing Process Nursing diagnoses Anxiety Pain Knowledge, deficient related to disease Infection, risk of Trauma, risk for Social interaction, impaired Self-esteem, risk for situational low

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. NURSING PROCESS Assessment Subjective Data Emotional Status Pain Nausea May be confused, disoriented or have decrease LOC due to hypoxia or fluid and electrolyte imbalances.

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. Objective Data Vital signs LOC Breath sound If Productive cough—color of sputum S/S of infection Urine Output (I & O) Bowel Sounds Signs of wound healing Mobility status Lab results Planning Implementation

Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. CLASSROOM ACTIVITY Identify appropriate nursing diagnoses for client with burn.